state of maine developmental services application for
TRANSCRIPT
State of Maine
Developmental Services
Application for Section 21 and Section 29
Waiver Services
Training for Mental Health and Children’s
Case Managers
Maine Department of Health and Human Services
1. What are Waiver Services …………………………………………………………Page 3-4
2. Section 21 and 29 Services ……………………………………………………….Page 5-7
3. Home Support Options …………………………………………………………….Page 8-10
4. Community Support Options ……………………………………………………...Page 11
5. Work Supports………………………………………………………………………Page12
6. Section 29 Application …………………………………………………………… Page 13-22
7. Section 21 Application …………………………………………………………… Page 23-33
8. Section 21 Prioritization …………………………………………………………..Page 34-38
9. Things to Consider While Waiting ………………………………………………..Page 39
10. Reconsideration of Priority for Section 21 …………………………....................Page 40-42
11. Wait List Notification Process ……………………………………………………Page 43-44
12. When an Offer is Received ………………………………………………….........Page 45-48
13. Links to all Forms and Protocols …………………………………………………Page 49
14. Contact Information …………………………………............................................Page 50
2
Table of Contents
➢ When a Member agrees to receive waiver services, they are waiving
their rights to an institutional care facility for individuals with
intellectual disabilities ( ICF/IID )
➢ Programs provided through Medicaid to assist Members with
receiving services in their homes and communities. Services must
be medically necessary.
What are Waiver Services?
3Maine Department of Health and Human Services
Medical Necessity or Medically Necessary services are those reasonably
necessary medical and remedial services that are:
1. Provided in an appropriate setting;
2. Recognized as standard medical care, based on national standards for
best practices and safe, effective, quality care;
3. Required for the diagnosis, prevention and/or treatment of illness,
disability, infirmity or impairment and which are necessary to improve,
restore or maintain health and well-being;
4. MaineCare covered services (subject to age, eligibility, and coverage
restrictions as specified in other Sections of the manual as well as Early and
Periodic Screening, Diagnosis and Treatment Services requirements as
detailed in Chapter II, Section 94 of the Maine care Benefits Manual.)
5. Performed by enrolled providers within their scope of licensure and/or
certification;
6. Provided within the regulations of the Mainecare Benefits Manual.
(References to Chapter 1.02 E of the Maine Care Benefits Manual)
https://www1.maine.gov/sos/cec/rules/10/ch101.htmMaine Department of Health and Human
Services4
What are Medically Necessary Services?
Section 21
Is a Comprehensive
Waiver Program for
Members with Intellectual
Disabilities (ID) or Autism
Spectrum Disorder (ASD)
Section 29
Is a Support Waiver
Program for Members
with Intellectual
Disabilities (ID) or Autism
Spectrum Disorder (ASD)
Maine Department of Health and Human Services
5
Section 21 and Section 29
Waiver Services
Section 29 Services
Maine Department of Health and Human Services 6
References to Ch. II, §29
of MaineCare Benefits Manual
Section 21 Services
Maine Department of Health and Human Services 7
References to Ch. II, §21
of MaineCare Benefits
Manual
Home Support-Quarter Hour (Section 21.07-17 and 29.05-6)
• Direct Support Professionals (DSP) come to the Member’s home to
assist with tasks and skills related to personal care, health, well-being,
and growth.
• Number of hours needed depends on the Member’s need for services .
• Ex: The Member may need support with laundry and meal-planning
or want someone to teach them how to manage their money. They
may need to learn skills to manage their medications or to maintain
their home or apartment.
For detailed information, please refer to:
https://www1.maine.gov/sos/cec/rules/10/ch101.htm (Section 21/29)
Home Support Options
8Maine Department of Health and Human Services
Shared-Living (Section 21.05-20 and 29.02-25)
• Is Adult Foster Care
• It is a per diem service but can be used less than 365 days a
year under Section 29.
• Members live in a private home and receive support from
another person(s) who lives in that home with them. This
person, or provider, must meet all the requirements of a Direct
Support Professional (DSP).
• Some supports include adaptive skill development, assistance
with ADLs, community inclusion and transportation.
For detailed information, please refer to:
https://www1.maine.gov/sos/cec/rules/10/ch101.htm (Section 21/Section 29)
Home Support Options
9Maine Department of Health and Human Services
Agency Group Home (Section 21.05-11)
• If the Member needs Agency Home Support, they would
live in a Group Home that varies between 2-6 members
who also receive support services.
• On-site daily support that includes personal care, protective
oversight, and supervision in accordance with the Member’s
Personal Plan.
• Staff are available 24 hours a day, 7 days a week to provide
the support that the Member needs.
For detailed information, please refer to:
https://www1.maine.gov/sos/cec/rules/10/ch101.htm (Section 21)
Home Support Options
10Maine Department of Health and Human Services
Community Support (Section 21.05-20 and 29.02-25)
• A habilitative service with a focus on community inclusion, personal
development, and support in areas of daily living skills if necessary. Goals are
to increase or maintain a Member’s ability to successfully engage in inclusive
social and community relationships and to maintain and develop skills that
support health and well-being.
• Provided by a Direct Support Professional employed by an OADS approved
provider.
• Flexible, responsive, and provided to Members as defined by the Member’s
choice and needs as documented in the Member’s Personal Plan.
• The location of the service and staffing level may vary, allowing for a mix of
individualized and group services.
• Allow for opportunities for career exploration and the facilitation of
discussions about the benefits of working.
Community Support Options
11Maine Department of Health and Human Services
Work Supports (Section 21.05-23 and Section 29.05-20)
• Maine is an Employment First state. This means that work supports are the
first and preferred service option. OADS believes all people can work and
provides supports to maintain employment.
• Assistance includes planning for employment, discovering interests and
abilities, and accessing services that will assist someone on their path to
employment.
• Obtaining employment and building skills in an integrated business
alongside of co-workers without disabilities making equitable wages and
benefits is the desired outcome.
• Includes Career Planning, Work Supports and Employment Specialist
Services
Work Supports
12Maine Department of Health and Human Services
Application Forms
Section 29
13
The Case Manager is responsible for submitting an Application for
Waiver services. An Application consists of the following :
1. A completed Developmental Services Home and Community Based
Waiver Assessment (BMS-99) (Word)
BMS99 is used to determine medical eligibility for waiver services
2. A completed Section 29 Cover Sheet (Word)
3. A completed Personal Plan Update Form (Word), signed by the
Individual/Guardian and the current Individual Service Plan (ISP).
Describes what staff will do to/with/for the Member.
4. A completed Yearly Cost Estimate for Services (Excel)
Completed Applications must be Emailed to [email protected]
Section 29- Supports Waiver
Application Process
14Maine Department of Health and Human Services
Maine Department of Health and Human Services 15
Maine Department of Health and Human Services 16
Maine Department of Health and Human Services 17
Maine Department of Health and Human Services 18
Maine Department of Health and Human Services 19
Maine Department of Health and Human Services
20
Yearly Cost Estimate for Services (Excel)
Maine Department of Health and Human Services
21
1. Community Support: Here is an example of 19 hours/weekly of Community Support (orange cell) and it’s annual cost of $25,806.56 ( blue cell)
2. Work Support: In this example the Member is receiving 7 hours/weekly of Work Supports (orange cell) and it’s annual cost of 12,317
3. Shared Living : Here is an example of Shared Living at 365 days per year(orange cell) and it’s annual cost of $56,940.00 ( blue cell)
4. Home Supports: Here is an example of a Member needing 23 hrs./week ofHS Quarter Hour (orange cell) and it’s annual cost of $37,076.00 (blue cell)
➢ Completed Applications must be Emailed to
➢ Applications are dated as they are received.
(BMS-99 in EIS also documents date received)
➢ Section 29 applications will be reviewed in the order they are
received and are placed on a waiting list based on receipt date.
➢ There are no priority levels in Section 29.
➢ If you do not receive an email confirmation within 2 business
days after emailing an application, please send an email to
➢ ** If you are unable to email your application, please email
[email protected] for further direction.Maine Department of Health and Human
Services22
Next Steps
Section 29 Support Waiver
Application
Section 21
23
The Case Manager is responsible for submitting an Application for Waiver
services. An Application consists of the following :
1. A completed Developmental Services Home and Community Based
Waiver Assessment (BMS-99) (Word)
BMS99 is used to determine medical eligibility for waiver services
2. A completed Section 21 Waiver Information Form (Word)
Assists waiver manager in determining the Member’s level of need
3. A completed Personal Plan Update Form (Word), signed by the
Individual/Guardian and the current Individual Service Plan (ISP).
Describes what staff will do to/with/for the Member.
4. A completed Yearly Cost Estimate for Services (Excel)
Completed Applications must be Emailed to [email protected]
Section 21- Comprehensive Waiver
Application Process
24Maine Department of Health and Human Services
Maine Department of Health and Human Services 25
Maine Department of Health and Human Services 26
Maine Department of Health and Human Services 27
Maine Department of Health and Human Services 28
Maine Department of Health and Human Services 29
Maine Department of Health and Human Services 30
Maine Department of Health and Human Services
31
Yearly Cost Estimate for Services (Excel)
The team determines how many units of support are necessary for each service. All information is entered in the orange cells only.
Maine Department of Health and Human Services
32
1. Community Support: In this example the Member is receiving 22.5 hours/weekly of Community Support ( orange cell) and it’s annual cost of $30,560.40 ( blue cell)
2. Work Support: In this example the Member is receiving 7 hours/weekly of Work Supports (orange cell) and it’s annual cost of 12,317
3. Home Support: Agency Group Home Per Diem: In this example the Member is receiving 168 hours of 24/7 supports (orange cell)
4. Shared Living : In this example the Member is receiving Shared Living at 365 days per year (orange cell) and it’s annual cost of $56,940.00
5. Home Supports: Quarter Hour: In this example the Member is needing 84 hours/week of HS Quarter hour (orange cell) and it’s annual cost of $135,408 (gray cell)
➢ Completed Applications must be Emailed to
➢ Waiver Manager processes/reviews applications for Section 21
and sets Priority Status.
➢ Waiver Manager Assistant sends letter to Member/Guardian
documenting medical eligibility and priority level assignment.
➢ If you do not receive an email confirmation within 2 business
days after emailing an application, please send an email to
➢ ** If you are unable to email your application, please email
[email protected] for further direction.
Maine Department of Health and Human Services
33
Next Steps
Section 21 Comprehensive Waiver
Section 21 PrioritizationPriority One (1), Two (2) or Three (3)
Members who are put on the Section 21 waitlist shall be served according to priority levels
34
Member meets Priority One (1) level if they are in need of Adult
Protective Services
OR
➢ Primary Caregiver has reached the age of 65 or has a terminal
illness and;
➢ Primary Caregiver is having difficulty providing necessary
supports to the Member and;
➢ Has no other responsible or willing Caregiver
OR
Maine Department of Health and Human Services
35
Section 21 Prioritization
Priority One (1)
The Member meets at least One (1) of the Following Criteria and is at risk of One (1) other:
a. Within 12 Months the Member has demonstrated a significant
medical/behavioral need by:
1. Functional Needs Have Increased
2. Involvement with the Criminal Justice System (not dependent
upon conviction) that impacts or results in harm or threat to
others
3. Prolonged or and unresolved crisis involvement resulting in
high-risk for hospitalization
4. Three (3) or more hospital admissions over the last 12 months
due to medical or behavioral decline that is expected to
continue
5. The Health, Safety or Welfare of the Member or Others is at
Imminent Danger
Maine Department of Health and Human Services
36
Section 21 Prioritization
Priority One (1), cont.
The Member does not meet Priority One (1) criteria, yet has been determined
to be at risk for abuse, neglect, and/or exploitation in the absence of the
provision of benefit services:
➢ A Member whose Primary Caregiver has reached age sixty (60) and is
having difficulty providing the necessary supports to the Member in the
family home; OR
➢ A Member living in unsafe or unhealthy circumstances but who is not yet
in need of adult protective services, as determined by DHHS Adult
Protective Services.
Maine Department of Health and Human Services
37
Section 21 Prioritization
Priority Two (2)
The Member is not at risk for abuse, neglect, and/or exploitation in the absence of the
provision of benefit services:
➢ A Member living with family, who has expressed a desire to move out of the
family home;
➢ A Member whose medical or behavioral needs are changing and who may not be
able to receive appropriate services in the current living situation;
➢ A Member who resides with family, if the family must be employed to maintain
the household but cannot work in the absence of the benefit being provided to the
member; OR
➢ A Member who has graduated from high school in the State of Maine, has no
continuing support services outside of the school system, but is in need of such
services.
For more information please refer to the MaineCare Benefits Manual
https://www1.maine.gov/sos/cec/rules/10/ch101.htm
Maine Department of Health and Human Services
38
Section 21 Prioritization
Priority Three (3)
Funding for waiver services is not a guarantee and it may take years before a Member can access services.
You may want to consider these options while waiting:
❖ Natural Supports
1. Family
2. Friends
3. Community Activities
❖ State Plan Services (MaineCare)
1. Residential Services (PNMI, Adult Family Care Services)
2. Community Programs ( Day Health Services)
3. Nursing Services
4. Nutrition
5. Health
6. Employment
❖ Other Waiver Services (can only receive one (1) waiver at a time)
1. Other Related Conditions Waiver- Section 20
2. Brain Injury Waiver- Section 18
3. Adults with Disabilities Waiver- Section 19
Maine Department of Health and Human Services
39
Things to Consider While Waiting
Reconsideration of Priority
Section 21
40
When there is any significant change in the Member or caregiver’s life, the
case manager can submit an updated Section 21 Application Packet to the
Waiver Manager to request a reconsideration of priority. Documentation
should reflect the change and event(s) that have occurred.
Some changes include and should be documented in the plan:
• Involvement with Adult Protective Services (APS)
• Loss of Natural Support
• Living Situation
• New Diagnosis or Member’s health is declining
• Caregivers age and their ability to support the members health and safety
needs
• Caregiver is terminal
Maine Department of Health and Human Services
41
Reconsideration of Priority for
Section 21
The Waiver Manager must receive:
• A completed Section 21 Waiver Information Form
(Word)
• A completed Personal Plan Update (Word), signed by the
Individual/Guardian and the current Individual Service Plan
(ISP).
• A completed Yearly Cost Estimate for Services (Excel)
• A completed Developmental Services Home and
Community Based Waiver Assessment (BMS-99)
(Word)
For these forms, please refer to:
http://www.maine.gov/dhhs/oads/provider/developmental-services/forms-
protocols.htmlMaine Department of Health and Human
Services42
Reconsideration of Priority for
Section 21
Waiting List Notification Process
Section 21
43
Maine Department of Health and Human Services 44
What To Do When An Offer Is
Received
Section 21 &29
45
➢ Member/Guardian (if applicable) will be notified by certified mail when an
offer is made.
➢ Member/Guardian has sixty (60) days from the date of the funded offer to
accept or decline the offer. Case Manager can notify the Waiver Manager of
decision.
➢ Member must be using waiver services within six (6) months from the date
of the offer.
➢ Failure by the Guardian and/or Member to Accept Services within sixty
(60) days and/or use services within six (6) months will result in the offer
being withdrawn per MaineCare Rule.
✓ If having difficulty starting services within the first four (4) months the
Case Manager should email the Waiver Manager to discuss obtaining an
extension.
Maine Department of Health and Human Services
46
Choose to ACCEPT Offer
Section 21 & 29
➢ Waiver Funding and the services provided are voluntary. The Member
and/or Guardian have the right to Accept or Decline Waiver Services.
➢ If Declining the Funded Offer: Case Managers, Guardian and/or Member
must submit a Declination-Voluntary Termination of Waiver Services Form
(Word) Form to the OADS Waiver Manager (Mail or Email).
➢ Some possible reasons to decline:
1. Member leaving the State
2. Member no longer interested in Section 21/29 Services
3. Member would like to accept another MaineCare Waiver and/or Service
Maine Department of Health and Human Services
47
Choose to DECLINE Offer
Section 21 & 29
Maine Department of Health and Human Services 48
Maine Department of Health and Human Services
49
Forms and Protocols
Current Forms and Protocols can be found at:
http://www.maine.gov/dhhs/oads/provider/developmental-services/forms-protocols.html
Cheryl Guimond LSW
Community, Mental Health and Children’s Case Manager Liaison
207-493-4116
Email any questions to Developmental Services Waiver Specialist
Office of Aging and Disability Services
Maine Department of Health and Human Services
41 Anthony Avenue - State House Station 11
Augusta, ME 04333-0011
50
Maine Department of Health and Human Services
Who To Contact With Questions